MEDICARE: PLATINUM LABORATORY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1851019715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLATINUM LABORATORY INC

Provider Business Mailing Address
First Line	:	4752 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5706
Country	:	US
Telephone Number	:	773-807-4508
Fax Number	:

Provider Business Practice Location Address
First Line	:	4752 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5706
Country	:	US
Telephone Number	:	773-807-4508
Fax Number	:	847-696-8488

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	UNKNOWN MOHAMMED KALEEM
Credential	:
Telephone Number	:	773-807-4508

Provider Enumeration Date	:	08/17/2022
Last Update Date	:	06/20/2024

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